Integrated Urgent Care in Gloucestershire Workshop
Notes and Actions from event on 2nd December 2016
Board & Biffen room, Sanger House
Present:
Mark Walkingshaw (Director of Commissioning Implementation, CCG) (MW)
Maria Metherall (Senior Commissioning Manager, CCG) (MM)
Gill Bridgland (Commissioning Implementation Manager, CCG) (GB)
Sally Jones (Programme Support Officer, CCG) (SJ)
Shaun Craney (Local Directory of Service Lead, Glos CCG) (SC)
Paul Wilkinson (Procurement Specialist, CCG) (PW)
Jim Atkinson (Severn Urgent & Emergency Care Project Manager) (JA)
Caroline Bennett (Urgent Care GP Lead, CCG) (CB)
Jo White (Primary Care Programme Director, CCG) (JW)
Ziyad Patel (Informational Analyst, CCG) (ZP)
Candace Plouffe (Chief Operating Officer, GCS) (CP)
Nick Evans (Operations Manager, OOH) (NE)
Sue Brooks (Head of Contracts, Care UK) (SB)
Sian Thomas (Deputy Chief Operating Officer, GCS) (ST)
Kay Haughton (Deputy Director of Nursing, CCG) (KH)
Dr Phillip Fielding (Gloucestershire Local Medical Committee) (PF)
James Attwood (Urgent Care Information Analyst, CCG) (JAttw)
Jo Bayley (Clinical Lead, GDOC) (JB)
Dr Magda Davis (GP, Forest) (MD)
Becky Parish (Associate Director Engagement/Experience, CCG) (BP)
Dr Jeevan Kulkarni (Medical Lead, SWAST) (JK)
Donna Miles (Lead Commissioner, CCG/GCC) (DM)
Una Rice (JUYI Project Manager, SCWCSU) (UR)
Julie Clatworthy (GB Nurse, CCG) (JC)
Mandy Hampton (Head of Capacity, GCS) (MH)
Ian Quinnell (Associate Director Programme Management, GHFT) (IQ)
Andrew Hughes (Implementation Manager, CCG) (AH)
Emily van de Venter (Public Health Registrar, GHFT) (EV)
Welcome and Purpose of the Workshop
MW gave overview of the purpose of the workshop as detailed in slide 2 of the powerpoint presentation accompanying these notes (to be circulated).
The group noted the current Gloucestershire OOH contract with SWASFT ends on 31st May 2017. The reprocurement has been a 2-stage process to realign with the NHS111 contract which ends in 2018 resulting in an integrated service.
National Context
MM gave national context arising out of the Urgent and Emergency Care Review (slide 3) and highlighting 5 key elements of change required (slide 4).
Current system and potential scope of Integrated Urgent Care Procurement
MM talked through the presentation.
Group discussion and feedback:
The group was split into 4 tables. Each group worked through the following questions and findings were written onto flipchart paper and discussed within the wider group. The findings and group discussion are summarised below - for the purposes of these notes, the findings have been grouped together.
Q1.What works well now and what doesn’t?
What are the MUST Dos we should include in the new service specification?
Works well:
  • Managing at the moment – just
  • Urgent & emergency needs met.
  • Engagement with services and Directory of Service (DoS)
  • Accurate DoS
  • Improved data sharing
  • Caring and committed workforce
  • Care planning, eg. exacerbation of long term condition.
  • High quality services – GPs CQC inspections, good pharmacy infrastructure, supportive CCG.
  • CHOICE+ although criteria needs opening up with more appointments and better access.
  • Community Hospital infrastructure – good geographical coverage.
  • NHS111 – capacity to take & manage high volumes, empathetic workforce, easy access.
Doesn’t work well:
  • Handling medication queries, especially at weekends. Too many of these calls coming through as red/urgent. Could go direct to pharmacy.
  • NHS111 – many pts don’t need full pathway, risk averse, inappropriate shifts pt expectation.
  • Pathways too risk averse.
  • Fragmentation of services, eg. community services/MIIUs/CHOICE+/OOHs – confusing to patients, different services/different names, too many options.
  • Access to alternative services – some options too often closed with public losing trust as their 1st option so choosing ED, public perception.
  • Access to diagnostics & knowledge of what’s available.
  • Confidence of carers – tendency to panic and call 999 before family or other alternative.
  • Duplication of contacts.
  • CHOICE+ - restricted criteria, not joined up, locums, destabilised workforce.
  • Workforce – needs system planning; redeployment of staff to respond to unpredicted increase in demand
  • Limited skills pool eg. ENPs/GPs – scarce resource.
  • Handovers eg. from NHS111 – lots of paper, next clinician has to pick out what’s relevant/urgent, risk. Suggestion of a “hot sheet”.
  • Inconsistent outcomes wherever you enter the system – variation of practice (perception).
  • IT – too many systems, not joined up.
  • OOH – sessional workforce with shifts not filled, offload from other struggling providers, integration with EDs and ward work.
Must Dos:
  • Decide and understand what we are talking about/dealing with; ownership.
  • 24/7 – differential in/out hours.
  • Pharmacy options – eg. call back or details of opening hours; call options – press XX for pharmacy advice, ?ENP nurse prescriber.
  • Upskilled triage.
  • Avoid fragmentation.
  • Core offer wherever you reside – including stabilising.
  • Integration and integrated IT solutions.
  • Collaboration of services & co-location, control access to front door.
  • Recruitment and retention, especially night staff.
  • Engage and value workforce.
  • Flexible deployment of appropriate staff as opposed to panic redeployment.
  • Improve resilience.
  • Access to urgent appointments with GPs/practices, ongoing/improved CHOICE+
  • Retain some pts through GP practices – not all pts can go through hub eg. ongoing needs/complex pts, need for physical vs phone.
  • Remember mental health patients.
  • Framework for covering unpopular hours ie. after 2pm on a Saturday.
  • DoS access to 111 data
  • Post 999 event message to GP surgeries.
  • “Hot sheet” handover
  • Voluntary/community service information as part of DoS
  • Public engagement/communication – promote healthy lifestyles.
  • Proper funding
  • Similar coverage as alternative to EDs.
  • Easy access.
  • Potential for local variation.
Other comments noted:
  • Identify themes of NHS111 calls, eg. to identify simple pharmacy/medication queries
  • Listen to the Welsh line – provides simpler options.
  • Should it be free at point of access?

Q2. Describe the Clinical Hub model for Gloucestershire.
  • What is it?
  • Get the basics right – analyse 111 to work out what services we need.
  • One route in, keep it simple, not too many layers/filters/options.
  • Look at Wiltshire model – currently open 08:00-18:30 Mon-Fri, then OOH.
  • Physical or virtual?
  • Physical:
  • Located in Gloucestershire? Co-located, local resilience, costs, infrastructure.
  • Local centres? – one in each locality, local variations, clinician triage, telephone option to tell pt to come in.
  • Urban vs rural
  • Walk-in vs non walk-in.
  • Opening hours.
  • Virtual ie. Skype, live chat.
  • no “eyeballing”, loss of visibility
  • GP remote triage
  • access to patient records crucial
  • ability to send the patient to the right place with informed choices
  • ?complex cases or frequent attenders
  • Seamless across 111 and 999 services.
  • Loss of “family doctor”, no reliance on familiarity, GPs working part/third time.
  • Streaming options – option XX for XX, Hub as 1st choice option.
  • Internet access across all areas?
  • 24/7
  • Pharmacy – access to pharmacists, collection of drugs, ie. FoD pts are a long way out.
  • Urgent care needs + community services, ie. dentist, GPs.
  • IT solutions / JUYI
  • Experts present with good skill mix in hub(s), ie. mental health, pharmacist, midwives, social care, GPs.
  • HCP professional line – for advice.
  • Telehealth – BP monitoring etc.
  • DoS – local knowledge, access to services.
  • In/Out hours differentials - access to services at all times, ie. social care in middle of night.
  • Presentation slide 6 – is this what the hub should look like? All of these services are in Glos with exception of CSD.
Other comments:
Mental Health services – what could that look like?
Q3.What are the standards we wish the Clinical Hub to deliver?
What are the significant obstacles we all face in delivery of the model?
Standards:
  • Meet or exceed?
  • Adhere to National ?OOH ?111 standards
  • One set, consistent 24/7, 365 days
  • Clear communications.
  • Clear specification & KPIs.
  • Structured process, outcome & quality driven measures,
  • Patient receives right advice, right service – 100% target. Patient experience & satisfaction.
  • Patient only articulates “problem” once.
  • Patient trust and expectations.
  • Staff experience & satisfaction
  • Call-back standards, eg. comfort calls.
  • Complain & compliment response coordination.
Obstacles:
  • Current culture within commissioning
  • Clearly defined problem
  • Human behaviour, resistence to change & energy.
  • Workforce recruitment – quality and quantity.
  • Not built around the patient.
  • Money – not enough funding to deliver ideal model.
  • IT.
  • Infrastructure.
  • Governance.
  • One size doesn’t fit all.
  • Collaboration vs competition. One big bid? Pooled approach?
  • OOH access to CHOICE+
Enabler:
  • Use benefits, incentivise, £/activity
  • UBER model, home-working, not zero-hours.

Closing Remarks and Next Steps
Slide 19 details the procurement timetable for both elements – Project A and Project B.